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NON-OBSTETRICSURGERY DURING
PREGNANCYJoy L. Hawkins, M.D.
University of Colorado SOM(* I have no conflicts to disclose.*)
GOALS & OBJECTIVESUpon completion of this presentation, participants will
be able to:
1. Explain issues related to teratogenicity
2 i h i k f i l2. Discuss the risks of occupational exposure to
anesthetics
3. Cite outcome studies of parturients having surgery
4. Develop a rational approach to anesthetic
management, including special surgical situations.
Br J Anaesth 2011; (S1): i72-i78
OUR PATIENTS ARE CONCERNED
Pregnant women who sought
counseling after exposure to non-teratogenic drugs estimated they had a g g y
25% risk of major malformations.
Am J Obstet Gynecol 1989;160:1190
THE PUBLIC IS CONCERNED
“The fetus usually dies from the
anesthesia administered to the mother
before the procedure begins . . . The p g
intravenous anesthetic administered to the
woman during the procedure induces a
medical coma in the fetus and eventually
a neurological fetal demise.”
Congressional Testimony 6/23/95
ANESTHESIOLOGISTS ARE CONCERNED
A retrospective survey of female veterinarians
related preterm delivery (< 37 weeks) to self-
reported occupational exposuresreported occupational exposures.
• OR 2.5 for those who performed surgery without
scavenging anesthetic gases vs. with scavenging
• OR 3.69 for those working > 45 hours a week.
Obstet Gynecol 2009;113:1008
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
CONTROVERSIALISSUES IN ANESTHETIC
CARE DURINGCARE DURINGPREGNANCY
Controversy #1. Which patients need to have preoperative
pregnancy testing?
Case: A healthy 25-year old woman
presents to your operating room for
knee arthroscopy on an outpatient
basis. Does she need to have a
pregnancy test?
50% of pregnancies in the U.S. are unplanned!
PREGNANCY TESTING
From the ASA Practice Advisory for Pre-anesthesia Evaluation:
“The Task Force recognizes that patients may present for anesthesia with early undetected pregnancyfor anesthesia with early undetected pregnancy. The Task Force believes that the literature is inadequate to inform patients or physicians on whether anesthesia causes harmful effects on early pregnancy. Pregnancy testing may be offered to female patients of childbearing age and for whom the result would alter the patient’s management.”
PREGNANCY TESTINGFor one year, all women of childbearing age having ambulatory surgical procedures had preoperative pregnancy testing.
• 7/2056 (0.3%) of tests were positive.( ) p
• All 7 patients elected to cancel surgery (2 were infertility procedures).
• The estimated cost to diagnose one pregnancy was $2879.
.
Anesthesiology 1995;83:690
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
PREGNANCY TESTINGA specialty orthopedic hospital initiated mandatory
pregnancy testing. After 1 year:
• 2588 tested�8 positives, but 4 were false positives.
• 3 of the false positives subsequently had a negative3 of the false positives subsequently had a negative serum hCG, and surgery then proceeded.
• 4/2588 (0.15%) of tests were true positives and their surgery was canceled.
• NNT for 1 true positive : 647
• Cost for 1 true positive : $3273
Anesth Analg 2008;106:1127
PREGNANCY TESTING
“…should a spontaneous abortion occur
after surgery, or the baby be born with
a congenital anomaly, this may be g y, y
attributed to the surgery or
anesthetic…….screening may
decrease litigation, although potential
cost savings are difficult to quantify.”
Anesth Analg 2008;106:1127
PREGNANCY TESTING
A retrospective review of 2 years of mandatory pregnancy
testing in a freestanding pediatric hospital revealed that
2.4% of patients age 16 and older were positive. None were
positive in patients less than 15 years of age (overall 1 3%)positive in patients less than 15 years of age (overall 1.3%).
Their conclusions: A policy of mandatory pregnancy
testing in patients aged 15 and older is advisable. Specific
written consent for the test is not necessary, but proper
notification processes must be established.
Anesth Analg 1996;82:4-7
PREGNANCY TESTINGWhat about ethical and privacy concerns?
• Can you test without the patient’s consent?
• Will you cancel the case if they refuse testing?y y g
• If positive, can/should you inform a minor’s parents?
If testing is required, patients should be informed they
will be tested, that they could be denied their surgery if
positive, and that the results will be on their medical
record and therefore potentially available to insurance
companies and/or their employers.
PREGNANCY TESTING
• Even if she was pregnant, how would you change
your anesthetic management?
Since there are no modern anesthetic drugs that we
know will affect the pregnancy or developing
embryo, testing is not medically indicated for
anesthetic management. Is testing an entire class of
patient just to protect the provider from liability
ethical?
PREGNANCY TESTINGDo pregnant women have greater morbidity after
surgery than non-pregnant?
• Using the NSQIP database from 2005-9, 857
appendectomy and 436 cholecystectomy casesappendectomy and 436 cholecystectomy cases
in pregnancy were reviewed.
• Morbidity was no different than non-pregnant.
• Pregnant women were more likely to be
infected.
Obstet Gynecol 2011;118:1261
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
Controversy #2. Are benzodiazepines and nitrous
oxide safe to use during pregnancy?
Case: A woman at 12 weeks gestation
requests general anesthesia for a
cervical cerclage placement scheduled
for ~ 20 minutes. She is extremely
anxious about the procedure and asks
you for preoperative sedation.
DOCUMENTED TERATOGENS
ACE Inhibitors Lead
Alcohol Lithium
Androgens Mercury
Antithyroid Drugs Phenytoin
Chemotherapy Agents Streptomycin
Cocaine Thalidomide
Coumadin Trimethadione
Diethylstilbestrol Valproic Acid
Isoretinoin
TERATOGENICITYHow long after a drug is marketed does it take to
establish safety for use in pregnancy?
• Experts assessed 469 drugs approved by the FDA
between 1980 and 2000 reviewing available studiesbetween 1980 and 2000, reviewing available studies.
• 91% of drugs were still classified as their risk of use
during pregnancy being “undetermined”.
• Inadequate information is available for women and
their physicians to determine risks of most drugs.
Obstet Gynecol 2002;100:465
NITROUS OXIDE
Pregnant rats given nitrous oxide 75% for 24
hours on day 9 of gestation had a 4-fold
increase in resorptions (abortions) and a 15-
fold increase in anomalies when compared
to rats given equi-anesthetic concentrations
of xenon.
Science 1980;210:899
NITROUS OXIDE
Why might N2O cause adverse effects?
N2O inactivates vitamin B12, a coenzyme of
methionine synthetase, causing depression
of methionine synthetase activity and
potentially affecting production of
thymidine and DNA.
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
NITROUS OXIDE
However, even very low concentrations of N2O
(<1%) will abolish methionine synthetase activity,
yet it requires 24 hours of high N Oyet it requires 24 hours of high N2O
concentrations (75%) to cause teratogenesis.
Are the adverse effects of nitrous oxide biochemical
(reduced methionine synthetase activity), or could
they be due to hemodynamic effects?
NITROUS OXIDE
• N2O enhances adrenergic tone and causes vasoconstriction.
H l th ( th l ti ) d th• Halothane (a sympatholytic) and other volatile anesthetics administered with N2O protect against major and minor anomalies in rodents. Folic acid does not.
Teratology 1988;38:121
NITROUS OXIDEThe largest retrospective study of exposure to
surgery and anesthesia during pregnancy
compared 5405 women who had surgery (of
720 000 t t l 0 75%) t t l720,000 total = 0.75%) to case controls.
• 54% had GETA, 97% of those had N2O
• No difference in stillbirth or anomalies
• Increase in IUGR and prematurity
Am J Obstet Gynecol 1989;161:1178
NITROUS OXIDE: SUMMARY
• Teratogenic effects in animal studies may be due
to vasoconstriction and decreased uterine blood
flow. Combine N2O with a sympatholytic agent.
Ad h ff h b• Adverse human effects have never been
documented, even in large outcome studies.
• Studies in modern hospital settings with O.R.
scavenging do not show an association with
nitrous and adverse pregnancy outcomes.
BENZODIAZEPINES
Two studies in 1975 reported an
association between maternal exposure
to benzodiazepines (Valium® and
Librium®) and cleft lip and/or palate.
Int J Epidemiol 1975; 4:37
Lancet 1975; 306:478
But later work refuted these reports.….
BENZODIAZEPINES
• 611 infants with cleft lip and/or palate were compared to 2498 control infants with other birth defects.
• The risk of clefts was no different between women who were or were not exposed to diazepam during first trimester of pregnancy.
• For cleft lip ± palate: RR 0.8 (0.4-1.7).
• For cleft palate alone: RR 0.8 (0.2-2.5).
NEJM 1983; 309:1282
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
BENZODIAZEPINES
• An NIH-supported prospective study did not find any increased risk of cleft anomalies associated with diazepam use:p
RR 1.2 versus controls
95% CI 0.17-8.95
NEJM 1984; 311:919
BENZODIAZEPINES
• A meta-analysis of 7 cohort studies
involving 1090 infants who were exposed to
benzodiazepines found no increased risk of
j lf i ifi ll lmajor malformations, or specifically oral
clefts (RR 1.19, CI 0.34-4.15).
• “Even when the worst case scenario is
assumed, benzodiazepines do not seem to be
major human teratogens….”
BMJ 1998;317:839
BENZODIAZEPINES
ACOG Clinical Expert Series on Teratogenicity“Anxiolytics (benzodiazepines): No evidence of significant risk of teratogenicity”
I i i l fi di f l f h b fi d b• Initial findings of clefts have not been confirmed by long-term follow-up studies.
• Overall results are reassuring, revealing no adverse effects on neurodevelopment.
• May be beneficial adjunct for hyperemesis (!)
Obstet Gynecol 2009;113:166
BENZODIAZEPINES
“An increased risk of congenital
malformations associated with the use
of benzodiazepine drugs . . . has been p g
suggested in several studies. If this drug
is used during pregnancy, the patient
should be apprised of the potential
hazard to the fetus.”
Roche, package insert for Versed®
Controversy #3. When and how should fetal monitoring
be used?Case 1: An elective cholecystectomy done at 34
k t tiweeks gestation.
Case 2: An emergency femoral thrombectomy at 31 weeks gestation.
Case 3: A series of 5 ECTs performed between 17 and 19 weeks of gestation.
INTRAOP MONITORING
• Blood pressure (normal or slightly above)
• Oxygenation, ventilation
• Temperature (avoid hyperthermia)
• Blood glucose for longer cases
• Fetal heart rate (FHR) > 24 weeks:
intermittent, or continuous if possible
• FHR < 24 weeks: preop and postop check
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
INTRAOP FETAL MONITORING
• This should not be discussed and decided as a
medicolegal issue! It is a medical issue.
• Monitoring may help assess placental perfusion
during induced hypotension, cardiopulmonary bypass,
volume shifts/blood loss.
• It provides an important reassurance for the mother.
• Helps assure the intrauterine environment is optimized
• But FHR monitoring is imprecise and not predictive of
outcome.
ELECTRONIC FETAL HEART RATE MONITORING (EFM)
EFM has a 98% false positive rate, yet is used in 85% of births. Does it prevent brain injury and/or death?
• 13 RCT and 3 observational studies were reviewed.
• EFM has no effect on cerebral palsy or perinatal death.
• EFM use does parallel the increase in cesarean rates.
• There are related increases in litigation and payments for negligent fetal injury, despite a lack of evidence that EFM can predict outcome.
Obstet Gynecol 2006;108:656
CASE 1: FETAL MONITORING
A patient at 34 weeks gestation required
cholecystectomy. During skin prep (before
any surgical intervention), severe persistent
f l b d di d Afetal bradycardia occurred. An emergency
cesarean was performed and the umbilical
cord was tightly coiled and twisted.
• Apgar scores = 1 / 5 / 7
• Umbilical cord pH = 7.17 and 7.18
Can J Anesth 2003;50:922
CASE 2: FETAL MONITORING
During the 30th week of an uncomplicated
pregnancy, a patient underwent femoral
thrombectomy under routine GETA. During
h f l i h d bsurgery the fetal monitor showed absent
variability, so an emergency cesarean delivery was
performed for presumed fetal distress. Umbilical
pH=7.23 (normal). The child was intubated for
prematurity and had to be admitted to the ICU.
Br J Anaesth 2001; 87:791
CASE 3: FETAL MONITORING
A series of ECTs was required in a woman between 17 and 19 weeks gestation. FHTs checked before and after the first 4
d l FHT i dprocedures were normal. FHTs monitored during the 5th procedure showed a severe deceleration. No intervention was done due to non-viability. She went on to deliver a normal healthy baby at 38 weeks.
Acta Anaesthesiol Scand 2003;47:101
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
FETAL MONITORINGWhat should you do for intra-operative fetal distress?
• � maternal FIO2 and blood pressure
• � left uterine displacement or try the right side
• Move the surgeons or their retractors
• Administer a tocolytic (terbutaline 0.25mg)
• Document your efforts in the record
** Remember: loss of BTBV is normal; decels are not.
** Consider preop / postop FHR monitoring for most
cases in consultation with the obstetricians.
Controversy #4. Should pregnant patients > 24 weeks
gestation have surgery in a specialty hospital without L&D
coverage?(no fetal monitoring, no capability for a C/S, no
neonatologists)
PERIOPERATIVE BACK-UP
Case: A woman at 28 weeks gestation was
evaluated for deteriorating vision, and a large
meningioma was found on MRI. Urgent g g
craniotomy was planned to preserve her
sight. The surgery proceeded without fetal
monitoring or provision for cesarean delivery
as obstetric care was not available at the
hospital where neurosurgery was performed.
Can J Anesth 2004;51:573
ACOG / ASA JOINT STATEMENT“Non-obstetric Surgery During
Pregnancy”
“Due to the difficulty of conducting large-scale
randomized clinical trials in this population,
th d t t ll f ifithere are no data to allow for specific
recommendations…When non-obstetric surgery
is planned, the primary obstetric provider should
be notified. If that provider is not at the
institution where surgery is to be performed,
another obstetric care provider with privileges at that institution should be involved.”
ACOG / ASA STATEMENT
If fetal heart rate monitoring is to be used:
“Surgery should be done at an institution
with neonatal and pediatric services; an p ;
obstetric provider with cesarean delivery
privileges should be readily available, and
a qualified individual should be readily
available to interpret the fetal heart rate.”
www.asahq.org, October 2009
Controversy #5. What is the best way to manage the EXIT
(ex-utero intrapartum treatment) procedure?
Case: A healthy gravida at term has a fetus
with a large neck mass found on
ultrasound. The mass is compromising its
airway and intubation will be required
immediately after delivery.
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
EXIT PROCEDURE(Ex Utero Intrapartum Treatment)
1. Maternal GETA is maintained with 2 MAC volatile agent and narcotics for uterine relaxation and to provide adequate fetal anesthesia.
2. After uterine incision and hemostasis, only the head and arm are delivered A pulse oximeter ishead and arm are delivered. A pulse oximeter is placed, IM relaxant and narcotic are given to the fetus. The placenta remains intact.
3. The trachea is intubated or tracheostomy is performed. Surfactant may be administered.
4. Once the airway is secure, volatile agent is discontinued, delivery is completed and oxytocics are begun.
Anesthesiology 2011;114:1446
Controversy #6. Is there a “best” anesthetic during
pregnancy to protect the fetal brain from neurotoxicity?
Do anesthetic drugs cause developing neurons to commit
suicide (apoptosis)?
Case: A healthy well-educated woman
requires emergency appendectomy at
26 weeks gestation. Based on
information she obtained on theinformation she obtained on the
internet, she questions you about the
effect of your general anesthetics on
her fetus’ developing brain.
ANIMAL STUDIES
In a simulated clinical scenario:
• 7-day old rats (0-6 months in humans) received 6 hours of general anesthesia: gmidazolam, nitrous oxide, isoflurane.
• Animals had memory/learning impairments, apoptotic neurodegeneration, hippocampal synaptic function deficits.
J Neuroscience 2003;23:876
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
ANIMAL STUDIESAre the adverse effects attributable to the
direct effects of anesthetics, or are they the result of factors we would not see clinically; eg high doses over longclinically; eg. high doses over long periods, acidosis, hypoxia, starvation?
Problems:
• Inter-species differences
• Simulating normal O.R. conditions
• Adequate monitoring
PRIMATE STUDIES
Are non-human primates also susceptible to anesthetic toxicity?
• Rhesus macaques received 5 hours of q1 MAC isoflurane while ventilated.
• There was a 13-fold increase in neuro-apoptosis in exposed animals, largely concentrated in the cerebral cortex.
Anesthesiology 2010;112:834
ANIMAL STUDIES
What are the fetal effects of maternal
anesthesia?
• Pregnant rats were exposed toPregnant rats were exposed to
isoflurane for 4 hours in mid-gestation,
equivalent to 2nd trimester in humans.
• Offspring had memory and behavioral
abnormalities.
Anesthesiology 2011;114:521
ANIMAL STUDIESFrom an accompanying editorial:
“…it is not clear which anesthetic technique
might be least toxic, nor has any general
anesthetic been convincingly shown to be more
toxic…certainly non-urgent surgery should
continue to be postponed until after pregnancy.
Considerations should be made to using
regional anesthesia when possible.”
Anesthesiology 2011;114:479
IS REGIONAL BETTER?
A retrospective study of adnexal mass surgery during pregnancy compared 137 women having general anesthesia with 71 h i i l h ihaving regional anesthesia.
The incidence of preterm labor was higher in the regional (30%) than the general (6%) anesthetic group. Both were higher than the non-surgical group (3%).
Int J Obstet Gynecol 2006;15:212
ANESTHETICMANAGEMENT OF THE
PREGNANTSURGICAL PATIENT
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
COMMON SURGERIES
The most common indications for
surgery unrelated to pregnancy:
1 Appendicitis 1:2000 pregnancies1. Appendicitis, 1:2000 pregnancies
2. Cholecystitis, 1:6000 pregnancies
3. Maternal trauma
4. Maternal malignancies
PREOP ASSESSMENT• Is my patient pregnant?
Document LMP on record.
Offer pregnancy testing.
• Operate during second trimester if possible• Operate during second trimester if possible.
Less risk of early spontaneous miscarriage.
Theoretical risks of teratogenicity are avoided.
3rd trimester � introp visibility, � preterm labor
• Reassure her about risks to fetus or pregnancy.
• Educate about uterine displacement, symptoms of preterm labor.
PREOP MEDICATIONS• Sedation
Narcotics
Benzodiazepines
• Aspiration Prophylaxis
Antacid
Metoclopramide
H-2 receptor blocker
MAGNESIUM TOCOLYSIS
Usual dose: 4-6 gm loading, then 2 gm/hr
I li ti N l bl k dImplications: Neuromuscular blockade
Attenuated vascular responses
Vasodilation
INDOMETHACIN TOCOLYSISUsual dose 50 mg loading,
25 mg q 6 hours PO or PR
Implications Maternal Fetal
Platelet function Necrotizing enterocolitis
GI symptoms Oligohydramnios
Renal insufficiency Closure of fetal ductus
CHOICE OF ANESTHETIC
• There is no evidence in humans (yet)
that any drug or anesthetic technique is
dangerous to the fetus.g
• Choose the safest anesthetic for the
mother’s condition, and modify for the
physiologic changes of pregnancy.
• Avoid hypoxia and hypotension!
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
GENERAL ANESTHESIA
• Full preoxygenation/denitrogenation
• Rapid sequence induction, smaller ETT
• First trimester: use tried and true drugsFirst trimester: use tried and true drugs
• Nitrous oxide versus FIO2
• ET CO2 28-32; avoid hyperventilation
• Inhalational agents < 2.0 MAC
• Slow or no reversal of relaxants
• Compression stockings
REGIONAL ANESTHESIA• Advantage of minimizing drug exposure
First trimester
Fetal monitoring
• Prevent hypotension
Adequate fluid replacement
Uterine displacement
• Decrease neuraxial local anesthetic dose by 30%
• Choose ephedrine vs. phenylephrine based on maternal heart rate
• Continue to provide postoperative pain control
POSTOPERATIVE CARE
• Continue monitoring fetal heart rate and uterine
activity. Provide L&D nursing expertise.
• Maintain maternal oxygenation and LUD.
• Notify Pediatrics if the fetus is a viable
gestational age > 24 weeks.
• Use neuraxial narcotics or regional blocks for
pain management if possible to encourage early
ambulation.
SPECIFICSITUATIONSSITUATIONS
TRAUMA• A leading cause of maternal death, especially
MVA without use of seat belts.
• Fetal loss is due to maternal death or placental abruption.
• Need earl ltraso nd in E R to determine• Need early ultrasound in E.R. to determine gestational age and viability.
• Perform all necessary diagnostic tests on the mother with shielding as necessary.
• Maternal � blood volume may mask blood loss.
Obstet Gynecol 2009;114:147
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
TRAUMAWhat are the risks of radiation exposure?
• ACOG has stated: “no single diagnostic x-ray
procedure results in radiation exposure to a
degree that would threaten the well being ofdegree that would threaten the well-being of
the developing fetus.”
• Teratogenic risks are not increased with < 5 rad
exposure (eg. a head CT < 1 rad).
• Ultrasound and MRI are safe alternatives.
Anesth Analg 2010;110:863
TRAUMAIndications for emergent C/S:
• Stable mother, viable fetus in distress
• Uterine rupture
• Gravid uterus interfering with repairs
• Mother unsalvageable, fetus viable
If the fetus is previable or dead, focus on optimizing
the mother. She will tolerate vaginal delivery at a
later time better than an emergent laparotomy.
NEUROSURGERY
• Intracranial aneurysms or AVM may require repair in this age group.
U l th ti t h i b d• Usual anesthetic techniques can be used.
• Fetal monitoring is remote from the field and may be beneficial in some cases, eg. aggressive diuresis, hyperventilation, bleeding and fluid shifts.
Anesth Analg 2008;107:193
NEUROSURGERYSuccessful endovascular treatment of acutely
ruptured intracranial aneurysms in pregnancy:
• 32 wks gestation with HA and vomiting. CT and
MRI show SAH and aneurysm: C/S � angio �MRI show SAH and aneurysm: C/S � angio �embolization with coils.
• 22 wks gestation with HA, vomiting, LOC. CT
shows SAH: GETA � angio � occlusion with
coils using fetal shielding � SVD at term.
Am J Obstet Gynecol 2001;185:1261
CARDIOPULMONARY BYPASSPregnant patients who had cardiopulmonary
bypass procedures were reviewed:
• Fetal prematurity or death were associated
with emergent procedures, maternal co-g p ,
morbidities, and early gestational age.
• Recommendations: normothermic, high-flow
bypass, postponing until 2nd trimester.
• Elective delivery before CPB should be
considered if the fetus is viable.
Ann Thorac Surg 2011;91:1191
GOALS DURING CPB
• High pump flows (>2.5 L/min/m2)
• High MAP > 65 mmHg
• Hematocrit > 28%• Hematocrit > 28%
• Normothermic CPB (limit < 320C)
• Pulsatile flow ?
• Optimize CO2, acid-base, glucose
• Continuous fetal HR monitoring
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013
LAPAROSCOPY
Symptomatic cholelithiasis during pregnancy is not
rare. Choice of medical versus surgical
management has been controversial.
• Compared to medical management, surgery
patients had less preterm labor, fewer premature
deliveries, and fewer days in-hospital.
• 38% of medical patients had relapses. Each
relapse accounted for additional 5 inpatient days.
Am J Surg 2004:188:755
LAPAROSCOPYIs laparoscopy better for fetal outcome than an
open procedure?
• There are no outcome differences between laparoscopy and laparotomy in maternal p py p ycomplications or fetal outcome.
• Laparoscopy patients (the mothers) had longer operative times but shorter hospital stays, less parenteral narcotics, and earlier resumption of regular diet.
Clin Obstet Gynecol 2009;52:557
LAPAROSCOPYFollowing laparoscopy (n=2181) or laparotomy (n=1522)
performed between the 4th and 20th weeks of gestation, there
were no differences in:
• Infant survival to one year
• Rate of fetal malformations
• Birth weight
• Gestational duration
• Growth restriction
There was an increased risk of low birth weight < 2500 gm,
delivery before 37 weeks, and growth restriction when
comparing the operated groups to the general population.
Am J Obstet Gynecol 1997; 177:673
GOALS FOR LAPAROSCOPY• Consider an open technique to enter abdomen
• Maintain normal end-tidal CO2, consider blood gas monitoring
• Keep inflation pressure < 15 mmHgKeep inflation pressure < 15 mmHg
• Can be used in any trimester of pregnancy
• Maintain uterine displacement and monitor the fetus if feasible
• Use compression devices for DVT prophylaxis
Surg Endosc 2008; 22: 849
SUMMARYApproach the pregnant surgical patient with
respect, rather than apprehension.
R i h f l t d t hRecognize her fears related to her pregnancy.
Doing what is best for the mother will almost
always be best for the fetus and the
outcome of the pregnancy.
Hawkins, Joy, MD Non-Obstetric Surgery During Pregnancy
CRASH 2013